Routine inspection·August 6, 2025

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:12AM. LPA met with staff and Licensee Ross Hashemi who arrived at 12:25PM. Entrance interview conducted. Beginning at 11:24AM, the LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguisher was fully charged and last purchased 09/01/2025. All hardwired smoke and carbon monoxide detectors were tested at 11:43AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were turned off. Staff turned the alarms on during the visit and were functional and operating. KITCHEN: LPA inspected the kitchen at 11:24AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. Sharp objects and cleaning supplies were stored in a locked and inaccessible cabinets. BEDROOMS/RESTROOMS: There are seven (7) bedrooms of which six (6) are private resident rooms and one (1) is a staff room. Staff room was observed to be unlocked. Five (5) rooms have exits to the exterior. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting. There are three (3) restrooms, two (2) are attached to resident rooms and one (1) is in the hallway for resident, staff, and visitor use. LPA observed bathrooms to be clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in all three (3) bathrooms and were between 105.3 F-108.0 degrees F, which is within the required range. Continued on LIC 809-C. COMMON SPACES: At the time of the visit, living room and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. LPA observed ring cameras in common spaces which contain an audio component and store and save recordings. LPA telephonically advised Administrator Michelle Maurer to disconnect the cameras and submit a waiver for the Ring cameras due to the audio component, to update plan of operation, and admission agreement. LPA observed the admission agreement to state that common areas will have “video surveillance” which “will not be recorded or stored,” however, the cameras observed during today’s visit have video and audio surveillance which are recorded and stored. Staff disconnected the cameras during the visit. GARAGE/LAUNDRY/GROUNDS : The garage is not accessible from the house and is used as a storage room; garage contained a washer and dryer, emergency food and water supply, and cleaning supplies. LPA observed the garage to be unlocked and accessible, staff locked the garage during the visit. The backyard exterior passageways were clean and clear of any obstructions. There is a side gate for emergency exit use and is single latched. There are tables and chairs for resident use. No bodies of water were noted in the backyard. MEDICATION REVIEW: Medications review began at 11:50AM; medications are centrally stored and locked in a closet at the entrance of the facility. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. At 11:58AM, LPA observed a medication error for Resident #1 (R1)’s Lovastatin 20mg medication. The medication was started on 06/14/2025 with a quantity of 100 pills and instructions for one (1) pill a day. LPA observed forty-two (42) pills in the medication bottle and one (1) prepared pill for tomorrow’s administration making a total of forty-three (43) pills; however, there should be forty-seven (47) pills according to the logged start date, quantity, and the medication instructions. Four (4) pills were unaccounted for, and no documentation could be provided. RECORD REVIEW: Beginning at 12:18PM, LPA reviewed four (4) staff and five (5) out of five (5) resident files for documents including but not limited to: resident Admission Agreement, TB test, medical assessments, appraisal, health screening, staff training and fingerprint clearance. All five (5) resident files and four (4) staff records reviewed were in compliance with regulation at the time of the visit. Continued on LIC 809-C. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 06/19/2025. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. Licensee was unable to be present for exit interview. Administrator designated Evangelina Roxas to sign the report. Exit interview conducted. Appeal rights and a copy of the report was provided.